1 INTRODUCTION

Uvulopalatopharyngoplasty (UPPP) is generally both safe and effective as a surgical treatment for non-obese patients who suffer with mild to moderate sleep apnea and severe snoring. This refinement in surgical technique¹ employs strategies for avoidance of complications and improvement of efficacy. Palatal dysfunction is avoided by minimization of soft palate shortening in the midline (uvula) area. Nasopharyngeal stenosis is avoided by minimization of posterior pillar resection and avoidance of pharyngeal undermining. Effectiveness of surgery is improved when emphasis is placed on opening the nasopharynx widely in the lateral port areas. Also, tissue removal deep in the inferior tonsillar poles (and hypopharynx) with mucosal advancement and suturing is emphasized.

2 SURGICAL PROCEDURE AND TECHNIQUE

Prophylactic antimicrobials (with anaerobic activity) are initiated 1 hour before surgery, with intravenous ampicillin/sulbactam (Unasyn 3 g) or clindamycin (900 mg).A preoperative corticosteroid intravenous injection is also given (Solu-Medrol 125 mg or dexametasone 10–15 mg). Preoperative sedatives are avoided because obstructive sleep apnea patients are often over-reactive to them and airway crisis may occur. Likewise, an anesthesiologist should be selected who is well aware of the compromised status of the airway in such patients. The orally intubated and anesthetized patient is placed in the head-extended supine position with the Crowe–Davis tonsillectomy mouth gag and the Ring tongue blade in place.

The areas to be surgically excised are injected with small amounts of epinephrine 1:100,000 solution (usually provided in 1% lidocaine). This is to promote hemostasis and is done by prior agreement with the anesthesiologist, who selects an appropriate inhalation agent.

The mucosa on either side of the uvula is clamped with hemostats and then incised in an oblique direction as in Figure 31.1. This severs the drooping mucosal web between the uvula and the posterior pillar, increases the mobility of the pillar, prevents soft palatal scar contraction (with ‘tethering’), and incises some of the lowermost fibers of the nasopharyngeal sphincter. Typically, the low-hanging soft palate of an apnea patient contains few muscular fibers of the nasopharyngeal sphincter.

Fig. 31.1 Pharyngeal view of apnea patient with absent tonsils, redundant mucosa, and drooping soft palate with webbing between uvula and tonsillar pillars. Begin by severing the uvulopalatal webs. This mobilizes the posterior pillars, releases the contracture, and prevents palatal tethering.

The palatopharyngeal incision is designed as three sides of a rectangle, as in Figure 31.2. It begins at the base of the tongue lateral to the inferior tonsillar pole and extends cephalad in the sulcus or angle formed between the internal surface of the mandible and the anterior tonsillar pillar. At about 1 cm above the level of the trailing edge of the soft palate, the incision makes a 90 angle, transverses the soft palate horizontally, then angles 90 downward again symmetrical to the opposite side. The ideal level for the horizontal palatal incision is at the location of the palatal ‘dimple’ as described by Dickson.⁴

Fig. 31.2 Box-shaped mucosal incision begins at tongue base, ascends in sulcus between anterior pillar and mandible, and then turns medially to cross soft palate about midway between trailing edges of soft and hard palates.

The soft palatal mucosa and submucosa (with glands and fat) are then stripped away from the muscular layers, beginning at the horizontal palatal incision and moving caudally toward the trailing edge of the soft palate and uvula. One or two brisk bleeders will often be encountered near the corners of the incision, and they must be suture-ligated with O plain catgut. (Cautery is inadequate and tissue-destructive, and it encourages stenosis.⁵) The uvula is amputated at the level of the trailing (caudal) edge of the soft palatal muscle fibers (Fig. 31.3). A tiny bleeder on each side of the uvula responds to a brief touch of electrocautery. Traction on the uvula during its amputation should be avoided because that results in excessive shortening of the uvula with interruption of the insertions of the levator palati muscles into the musculus uvulae. Loss of palatal sphincteric action (required for closure during speech and swallowing) has been attributed to excessive excision of the uvula and midline palatal tissue.

Fig. 31.3 Mucosa, glands, fat, and fibrous tissue removed down to but not through muscular layers. Uvula amputated at trailing edge of soft palatal muscle fibers.

Tonsils (present in one-third of snoring and apnea patients) are excised, and other soft tissues between the posterior tonsillar pillars and the lateral incisions are all stripped out, down to the muscular layers. The plane of dissection is readily apparent when a tonsillectomy is performed. However, if a previous tonsillectomy was done, dense fibrous scar tissue will be encountered that will inhibit mobilization of the posterior pillars. This fibrous scar should be carefully stripped away from the underlying muscle fibers of the tonsillar fossa (superior pharyngeal constrictors); the dissection should avoid damage (and cautery) to the musculature so as to avoid penetration through the muscle into the underlying structures of the carotid sheath.⁵

Bleeders are clamped and suture-ligated (which is less traumatic to the musculature and carotid sheath than is heavy electrocoagulation); good hemostasis is essential. Dissection below (caudal to) the lower pole of the tonsil is carried as far as visibility and safety allow, at which point lymphoid aggregations there and on the base of the tongue (lingual tonsils) may be reduced with gentle electrocoagulation.

The posterior tonsillar pillar is then advanced in a lateral-cephalad direction toward the corner of the original palato­pharyngeal incision (Fig. 31.4). Contiguous submucosal muscle fibers should be incorporated in this advancement because such a maneuver will increase the lateralizing effect and will expand the lateral dimension of the pharyngeal airway. This should also smooth and flatten out the redundancy and vertical folds of the posterior pharyngeal mucosa.³

Fig. 31.4 Posterior pillar is advanced in cephalad-lateral direction to increase lateral dimension of oropharyngeal airway. Pharyngeal redundancy is reduced.

Note that the best results are obtained from resection of the anterior pillar rather than the posterior pillar. This is because, when the intact posterior pillar is pulled forward (to cover the tonsillar fossa and to meet the incision of the resected anterior pillar), the soft palate will move along with it in a forward direction, thus enlarging the anterior posterior dimension of the nasopharynx. Conversely (and adversely), if the posterior pillar were to be resected, the closure would pull the anterior pillar and soft palate posteriorly, thus narrowing the nasopharynx.¹

The pillar is advanced and fixated into its new, lateralized position with multiple sutures of 3–0 polyglycolic acid (Dexon-‘S’) or polyglactin 910 (Vicryl). The sutures should pass through the mucosa into superficial muscular layers so as to lateralize the muscular as well as the mucosal elements of the pillars (see Fig. 31.5). Furthermore, such closure eliminates ‘dead space’ where hematomas might accumulate. I prefer to put in the second stitch before I tie the first knot so that the positioning is more visible. Suturing then progresses downward (caudally) toward the tongue base, where a small opening is left unsutured to allow for spontaneous drainage.

Fig. 31.5 Sutures pass through mucosal edges and also through superficial muscular layers to maximize lateralization of posterior pillar, to prevent hematoma formation, and to provide mucosal coverage of surgical defect.

The dissection and closure on the opposite side are identical (see Fig. 31.5).

Then the palatal closure is accomplished as the nasopharyngeal (posterior) surface of the soft palate mucosa is advanced over onto the oral (anterior) surface (Fig. 31.6). Redundant or flabby mucosa is trimmed, and the sutures are put into place, including a small amount of muscle fiber in the closure. Notice that the incisional/suture lines face forward (anteriorly), away from the nasopharynx and away from the caudal margin of the soft palate. This gives added protection against nasopharyngeal stenosis.

Fig. 31.6 Nasopharyngeal surface of soft palate is advanced forward to meet the incision on the oral surface and to cover the surgical defect on the oral surface. Forward-facing suture line minimizes risk of stenosis. It also expands the anterior–posterior dimension of the nasopharyngeal airway. Note rectangular appearance designed to minimize nasopharyngeal regurgitation.

3 POSTOPERATIVE MANAGEMENT

Intravenous antimicrobial prophylaxis is maintained for 48 hours (Unasyn or clindamycin). During surgery asingle dose of a corticosteroid is given (e.g. dexametasone10–15 mg intravenously) and if swelling/edema or excess pain begins to be apparent early in the postoperative period, a short course of corticosteroids is given (up to every 4 hours for four doses, then every 8 hours for four doses). Many apneic patients are already hypertensive before surgery or are hypertensive immediately afterwards. Salt overloading with intravenous fluids contributes to this problem, and anti-hypertensive therapy is often required.

Any patient with significant obstructive sleep apnea before surgery will need vigilant postoperative monitoring of respirations. The intensive care unit is frequently the ideal place for the first 24 hours after surgery.⁶

Postoperative care for simple-snoring patients is the same as that for adult tonsillectomy patients. However, for obstructive sleep apnea patients, pain medication is given more cautiously (i.e. low-dose parenteral morphine or oral elixir of acetaminophen with added codeine, 30 mg/5 ml), with the recognition that apnea is aggravated by narcotics, and that life-threatening loss of airway can be precipitated, especially in the postanesthetic period or the period of postoperative edema of the airway.^1,5,6

Similarly, anti-emetics, sleeping medications, and sedating tranquilizers can precipitate an apneic crisis; therefore, my nurses are instructed never to accept a telephone order for any of those medications by a physician who is not personally acquainted with my particular patient and his or her disease.

The criteria for discharge include a secure airway, adequate intake of fluids, and pain control with oral medications. The patient is sent home with instructions to avoid foods or drinks that are salty, scratchy, or sour. Liquid acetaminophen with codeine suffices for pain relief. Superficial wound contamination with oral microbial flora creates the equivalent of aphthous stomatitis at the surgical site. Recovery proceeds more rapidly if the patient uses the following ‘canker-sore’ mixture and procedure⁷:

4 RESULTS

Many – but not all – patients who undergo UPPP achieve remarkable relief of their snoring and excessive daytime sleepiness. Patient testimonials abound about lives having been dramatically changed. Furthermore, some studies suggest that the surgery, if successful, reduces to normal the exaggerated cardiovascular death rates seen in untreated obstructive sleep apneic patients.⁸

Unfortunately, UPPP does not always yield favorable results, and sometimes patients who enjoyed initial improvements will regress within 6–12 months later, especially if they regain body weight (against the physician’s strenuous advice). Furthermore, other sites of airway compromise may need to be addressed, such as nasal airway obstruction, hyperglossia, or skeletal deformities such as retrognathia.

Acknowledgment

Figures 31.1–31.6 are reprinted from Snoring and Obstructive Sleep Apnea, 3rd edn. Fairbanks DNF, Mickelson SA, Woodson BT, eds. Philadelphia: Lippincott Williams & Wilkins; 2003, with permission.